GW1--04183_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information:
14.WATER-ZONES_
Bobby W. Potts mom To •• r DESCRIPTION
Wall Contractor Name R '3 50 it _ •
NCWC 2028-A n 5(." ft
NCWdIConuactor�-^�.c��onNnmber ' 15.0> R.�ING(Teemnaimedwads)ORL1NEROfvpliable)
FROM TO DThME1dR THICYNPSs MATERIAL
Ferguson's Well and Pump, LLC • ft 7=' .- r)l 5 ia. I n 5. c5I),2Z/,
Company Name 16LTNNER CASING OR (Ileialosmal dated-1oo2)
FROM TO DIMMER THICKNESS MATT THAL
2.Well Construction Permit#: 4 B 5 a ft. ft ht.
Liu all applicable well canstrnedon pam/1s(ie.County,Stale,'ariace etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SZE THICKNESS MATERIAL
❑Agricultural ❑ lie ft ft
°Geothermal(Heating/Cooling Supply) DResidential Water Supply(cinglr) ft ft m.
❑IndusttiaUCommercial ❑Residential Water Supply(shared) iS.GROUT -
FROM TO MATERIiL n.oLACEMENT mETHoD&AMOUNT
ClInigation
Supply Well: ft 20 le' Concrete Gravity-Flow
Non-Water❑Monitoring ❑Recovery ft_ _ ft -- —,
Injection Well; it. ft
❑Aquifer Recharge ❑Groundwater Remcdiation 19.SAND/GRAVEL PACK feel algdtaibie) '
PROM _TO MATERIAL EMPLACEMENT METT3OD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft
DAquifer Test ❑Stomnwater Drainage '
ft. ft
❑Experimental Technology ❑Subsidence Control - o
❑Gcuthctmal(Closed 20.DRILLING LOG(attach addiSond shad ifn cessrA
Loop) ❑Tracer FROM TO DFSC'RIPTION(color,to de re,son/rock typr,_erato di.,.ta)
❑Geothermal(Heating/Cooling Rearm) OOthe(explain under#21 Remarks) () f • 5c ft C feeo V
4.Date Wens)Completed: '�i ti/�4'' Wel1ID# �()1 far ?� it c( - a3
5a.Well Location: • 7C/ ft- 7 ' R —
lU �-4F,tan �-1�-� 7t�'f`' _�"(o S. ft r�acw; c,
ft. ft •
Faci(ity/OwoerName Facility ID#(if applicable)
—
ft. ft
335 PST t-4.a'L q - inn R rc N<<t tip,7 sy ft. ft - l;.
Pb uics1 Address,City,and Zip 21 REMARKS _ 1 1 71171
( - to at toSC rl q`75'7-(.5 -53a7
Corty Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: •(if well field,one ladong is sufficient) 22 C A..
/V: VS —V Y9(S1' N cA03/5Rt 1(5a �r w 44 � ' � .i� , �� /�1�
/ Signanue Certified Well Conaway/ Date /
6.Is(are)the well(a): O'I'ermanent or OTemporary
By stgnang this form,I hereby urtify that the well(s)was(were)constructed to accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Conurucac►:Standards and that a
7.Is this a repair to an existing well: ❑Yes or • o copy rf this record has been provided to die well owner.
If this is a repair,fill out known well construction information and explain the native of the
repair wader#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: ( construction details. You may also attach additional pages if nrrrlstnuy.
For infection or noe-watermapp wells ONLY wide the same con traeia,you cm:aun SUBMITTAL INSTUCTIONS
9.Total well depth below land surface. 5- , (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For n sltlple wells lit all depths fd 'erost(example-3®200'and 2( 100') construction to the following:
10.Static water level below top of casing. a 5—C ' (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
b /
11.Borehole diameter: . (Q (n.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above, also subunit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) ! Method of teat Blowing-Rig 24c.For Water Smolb&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine 7 Amount i,J OZ. completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013 •